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Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
MA07.058j

Policy

The Company has delegated the responsibility for utilization management activities for the following sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM) with the exception of services performed in the emergency room or during an inpatient or observation unit stay.

For information on policies related to this topic, refer to the Cross References section in this policy.

Please refer to the References section of this policy for a link to applicable LCD, NCD, or the entire AIM Clinical Appropriateness Guidelines for Sleep Disorder Management, that are part of this program, as well as all applicable procedure codes.

AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations [LCD], National Coverage Determinations [NCD]). If no Medicare guidelines exist, AIM will utilize their AIM Clinical Appropriateness Guidelines for Sleep Disorder Management to determine medical necessity for these services.
  • Facility-based sleep disorder testing and positive airway pressure (PAP) titration
  • Positive airway pressure therapy
  • Supplies related to PAP therapy


BILLING REQUIREMENTS

For those specific circumstances where less than six hours of monitoring and recording of PSG are utilized or warranted, specific documentation must be maintained in the individual's record as to why a shortened study was medically necessary. Under these circumstances, the PSG would be billed with the 52 modifier to signify that a "reduced service" was performed and will be reimbursed accordingly.


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, sleep disorder testing and positive airway pressure therapy services and supplies are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria for the services and supplies are met.

However, services that are identified as not medically necessary or experimental/ investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of single-level continuous positive airway pressure (CPAP), auto-adjusting positive airway pressure (APAP), and bi-level positive airway pressure (BPAP) for obstructive sleep apnea and/or respiratory insufficiency caused by central and/or mixed apneas and periodic breathing.

Description

The Company has delegated the responsibility for utilization management activities for the following facility based sleep disorder testing and positive airway pressure therapy services and supplies to AIM Specialty Health® (AIM). To determine medical necessity for these services, AIM first utilizes Medicare guidelines (e.g., Local Coverage Determinations (LCD), National Coverage Determinations NCD). If no Medicare guidelines exist, AIM will utilize their Clinical Appropriateness Guidelines for Sleep Disorder Management to direct the application of these services for our members. Multiple sources were used to develop these guidelines, including technology assessments, peer-reviewed medical literature, clinical outcomes research, and consensus opinion in medical practice. The primary resources include:
  • Academy of Sleep Medicine
  • Agency for Healthcare Research and Quality
  • American Academy of Family Physicians
  • American Academy of Otolaryngology—Head and Neck Surgery Foundation
  • American Academy of Pediatrics
  • American College of Physicians
  • American Thoracic society
  • Canadian Agency for Drugs and Technologies in Health

References


AIM Specialty Health®. AIM Clinical Appropriateness Guidelines for Sleep Disorder Management. 2022. [AIM Web site]. 09/11/2022. Available at: http://www.aimspecialtyhealth.com. Accessed April 1, 2022.

Centers for Medicare and Medicaid Services (CMS). Coverage Decision Memorandum for Sleep Testing for Obstructive Sleep Apnea (OSA) 100-3, Change request 6543. [CMS Web site]. 2009. Available at: http://www.cms.gov/transmittals/downloads/R103NCD.pdf. Accessed April 1, 2022.

Centers for Medicare & Medicaid Services (CMS). CMS Manual System.Pub 100-04 Medicare National Coverage Determinations. Transmittal 2679 Revised and Clarified Place of Service (POS) Coding Instructions. [CMS Web site]. 03/29/2013. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2679CP.pdf. Accessed April 1, 2022.

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions Related to Change Request 7631 (Revised and Clarified Place of Service Coding Instructions). [CMS Web site]. 04/25/2013. Available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQs-CR7631-4-25-13.pdf. Accessed April 1, 2022.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).240.4: Continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). [CMS Web site]. 3/13/2008. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=226&ncdver=3&DocID=240.4&NCSelection=NCA|CAL|NCD|MEDCAC|TA|MCD&kq=true&SearchType=Advanced&bc=IAAAAAgAAAAAAA==&. Accessed April 1, 2022.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).240.4.1: Sleep Testing for Obstructive Sleep Apnea (OSA). [CMS Web site]. 3/3/2009. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=330&ncdver=1&DocID=240.4.1&kq=true&SearchType=Advanced&bc=IAAAAAgAAAAAAA==&. Accessed April 1, 2022.

Centers for Medicare and Medicaid Services (CMS). Pub 100-03 Medicare National Coverage Determinations, Change request 6048. [CMS Web site]. 10/15/2008. Available at: http://www.cms.hhs.gov/Transmittals/Downloads/R96NCD.pdf. Accessed April 1, 2022.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33718: Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea. [NHIC Web site]. Original: 10/01/2015. Revised: 08/08/2021.  Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33718.  Accessed April 1, 2022.

Noridian Healthcare Solutions, LLC. Local Coverage Article A52467: Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea-Policy Article. [NHIC Web site]. Original: 10/01/2015. Revised: 08/08/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52467. Accessed April 1, 2022.


Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33800: Respiratory assist devices. [NHIC Web site]. Original: 10/01/2015. Revised: 08/08/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33800.  Accessed April 1, 2022.


Noridian Healthcare Solutions, LLC. Local Coverage Article A52517: Respiratory assist devices-Policy Article. [NHIC Web site]. Original: 10/01/2015. Revised: 08/08/2021. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52517. Accessed April 1, 2022.

Novitas Solutions. Local Coverage Determination (LCD). L35050: Outpatient Sleep Studies [Novitas Web site]. Original 10/01/2015. Revised: 01/01/2021. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=35050&ver=55&bc=CAAAAAAAAAAA.  Accessed April 1, 2022.

Novitas Solutions. Local Coverage Article A56923. Billing and Coding: Outpatient Sleep Studies. [Novitas Web site]. Original 12/02/2021. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56923&ver=13&Date=02/03/2020&SearchType=Advanced&ContrId=&DocID=A56923&search_id=&service_date=&bc=JAAAAAgAAAAA&. Accessed April 1, 2022.

Novitas Solutions. Local Coverage Determination (LCD) L36839. Polysomnography and Other Sleep Studies. [Novitas Web site]. Original 02/16/2017. Revised 07/28/2021. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36839&ver=17&Date=&DocID=L36839&bc=iAAAABAAAAAA&. Accessed April 1, 2022.

Novitas Solutions. Local Coverage Article A56903. Billing and Coding: Polysomnography and Other Sleep Studies. [Novitas Web site]. Original 08/29/2019. Revised 07/28/2021. Available at:https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=56903&ver=4&LCDId=36839&Date=&DocID=L36839&bc=iAAAABAAgAAA&. Accessed April 1, 2022.

Trikalinos TA, Ip S, Raman G, et al. Home diagnosis of obstructive sleep apnea-hypopnea syndrome. AHRQ Technology Assessment Program. [CMS Web site]. 08/08/2007. Available at: http://www.cms.hhs.gov/determinationprocess/downloads/id48TA.pdf. Accessed April 1, 2022.
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Coding

CPT Procedure Code Number(s)
95782, 95783, 95805, 95807, 95808, 95810, 95811

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
Follow AIM Guidelines for medical necessity

HCPCS Level II Code Number(s)
A4604 Tubing with integrated heating element for use with a positive airway pressure device 
A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028 Oral cushion for combination oral/nasal mask, replacement only, each

A7029 Nasal pillow for combination oral/nasal mask, replacement only, pair

A7030 Full face mask used with a positive airway pressure device, each

A7031 Face mask interface, replacement for full face mask, each

A7032 Replacement cushion for use on a nasal application device mask interface, replacement only, each

A7033 Pillow for use on a nasal cannula type interface, replacement only, pair

A7034 Nasal interface (mask or cannula type) used with a positive airway pressure device, with or without head strap

A7035 Headgear used with a positive airway pressure device

A7036 Chin strap used with a positive airway pressure device

A7037 Tubing used with a positive airway pressure device

A7038 Filter, disposable, used with a positive airway pressure device

A7039 Filter, nondisposable, used with a positive airway pressure device

A7044 Oral interface used with a positive airway pressure device, each

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, only

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0561 Humidifier, non-heated, used with positive airway pressure device

E0562 Humidifier, heated, used with positive airway pressure device

E0601 Continuous positive airway pressure (CPAP) device

THE FOLLOWING CODE IS USED TO REPRESENT CPAP / BPAP DEVICES

E1399 Durable medical equipment, miscellaneous


Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

9/11/2022
9/11/2022
MA07.058
Medical Policy Bulletin
Medicare Advantage
No